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INSTRUCTIONS FOR
ADVANCE HEALTH CARE
DIRECTIVE (in accordance with the Uniform Health Care Decisions Act, 1999)
Complete Part 1 and 2 on the enclosed form. You may add pages and
make any changes you wish. You do not need an attorney to complete this
form. If you need more help, consult the phone numbers included in this
brochure. Complete the check list on the back page.
PART 1 – INDIVIDUAL
INSTRUCTION
Give instructions to your doctor and others about any aspect of your
health care. You will be given choices. Check only one box in each
category and cross out all which do not apply.
PART 2 – HEALTH CARE POWER OF ATTORNEY, YOUR AGENT
Select one or more persons to be your agent and make health care deci-
sions if you are unable. The person you appoint can be a spouse, adult
child, friend, or any other trusted person. Your agent cannot be an owner
or employee of a health care facility where you are receiving care unless
they are related to you.
Ask two witnesses to sign and date the form
Both must be people you know. They cannot be health care providers,
employees of a health care facility, or the person you choose as an agent.
One person cannot be related to you or have inheritance rights.
Notary Public
If you do not have 2 witnesses, your Advance Directive must be notarized.
You have the right to revoke or change your Advance Directive at any
time orally or in writing. Be sure to tell your agent and doctor.
WHO CAN HELP ME COMPLETE MY ADVANCE DIRECTIVE?
Kauai: Seniors Law Program 808-246-0573
Maui, Molokai, Lanai: Legal Aid Society 808-242-0724
Oahu: UH Elder Law Program 956-6544
www.hawaii.edu/uhelp
Big Island: Legal Aid Society (Hilo) 808-934-0678
(Kona) 808-329-8331
For further information contact:
Kokua Mau (Continuous Care) website at
www.kokuamau.org.
Kokua Mau Speaker’s Bureau: (800) 474-2113. Churches, Temples or
Spiritual Groups can ask about the Complete Life Course.
WHY DO
I NEED AN ADVANCE DIRECTIVE?
Medical technology has given us many new options for sustaining life.
This makes it important for you to discuss what kind of care you want
before serious illness or accident occurs.
Now is the time to talk about these important issues while you can still
make your own decisions and have time to talk about them with others.
If you don’t have an Advance Directive and even one person interested in
your care disagrees, your doctor may not honor your wishes for end-of-life
care.
The Advance Directive takes the place of the former living will document
and gives you more options. Review your existing forms to decide if an
Advance Health Care Directive will better reflect your wishes.
WHAT DO
I PUT IN MY ADVANCE DIRECTIVE?
THE KIND OF HEALTH TREATMENT YOU WANT
OR DON
’T WANT.
You can say whether or not you want to be kept alive by machines that
breathe for you or feed you even if there is no hope you will get better.
YOUR WISHES FOR COMFORT CARE
.
You can indicate whether you want medicine for pain or where you want
to spend your last days. You can also give spiritual, ethical, and religious
intructions.
THE PERSON OR “AGENT” YOU WANT TO MAKE DECISIONS
FOR YOU WHEN YOU CANNOT
.
This agent does not have to be an attorney. Unless you limit your agent’s
authority, your agent has the right to accept or refuse any kind of medical
care and testing, discharge or select doctors, and see all medical records.
HOW CAN I ENSURE MY ADVANCE DIRECTIVE
IS HONORED
?
Share copies and talk with people who will be involved in your care. Ask
your doctor to insert your Advance Directive into your medical records.
Register your Advance Directive free of charge at www.MyHealthDirec-
tive.com or call 587-4781.